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Esophageal Emergencies. Tintinalli chapter 75. Anatomy/Physiology. Muscular tube 20-25 cm long Majority in mediastinum, post/lat to trachea Outer longitudinal & inner circular muscles Upper 1/3 striated muscle, lower half all smooth muscle

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Esophageal emergencies l.jpg

Esophageal Emergencies

Tintinalli chapter 75

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  • Muscular tube 20-25 cm long

  • Majority in mediastinum, post/lat to trachea

  • Outer longitudinal & inner circular muscles

  • Upper 1/3 striated muscle, lower half all smooth muscle

  • Two sphincters; UES cricopharyngeus muscle, LES lower 1-2 cm of esophagus

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  • Three anatomic constrictions:

    • Cricopharyneus

    • Aortic arch/left mainstem bronchus

    • Gastroesophageal junction

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  • Innervation mirrors cardiac, a convergence of somatic and visceral stimuli; cardiac and esophageal chest pain similar.

  • Blood supply; inferior thyroid artery, branches from thoracic aorta, branches from left gastric and inferior phrenic arteries.

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  • Venous; submucosal plexus drains into plexus outside of esophagus

  • Outer plexus to :

    • Inferior thyroid

    • Azygos

    • Coronary

    • Gastric venous system

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  • Defined; difficulty swallowing

    • Majority will have organic process

  • Two types:

    • Transfer dysphagia; early in swallowing process

    • Transport dysphagia; impaired movement down esophagus through LES, perceived later in process, feeling of food “getting struck”

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  • Transfer:

    • 80 % neuromuscular; CVA,scleroderma, myasthenia gravis, parkinsons, lead poisoning, thyroid disease

    • Risk of aspiration

    • Discoordinated food bolus transfer to esophagus

    • Symptoms; gagging, coughing, nasal regurg.

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  • Transport:

    • 85 % obstructive disease; foreign body, carcinoma, webs, strictures, thyroid enlargement, vessel abnormalities, diverticuli

    • Less aspiration risk

    • Improper transfer from esophagus to stomach

    • symptoms; food sticking, retrosternal fullness, odonophagia

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  • History

    • Acute vs. chronic

    • Solids vs. liquids

    • Intermitent or progressive

    • Feeling of “something stuck”

  • Physical exam; focus on head and neck and neuro, helpful to watch pt swallow sip of water. Physical exam often normal.

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  • ED work-up: AP & lat neck x-rays. CXR.

    • Diagnosis often made outside ED. Barium swallow usually first test. Ultimately best worked up with video-esophagography.

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Structural/Obstructive causes

  • Neoplasm: common cause of both types.

    • 95 % squamous cell

    • Male : female , 3:1

    • Fast progression from solids to liquid dysphagia

    • Pts >40 yo with dysphagia assume neoplasm. Need expedient work up to rule out malignancy

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Structural/Obstructive causes

  • Esophageal stricture: results from scaring from GERD

    • Generally distal esophagus, may interfere with LES

    • Symptoms develop over years, usually only solids

    • Must rule out malignancy

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Structural/Obstructive causes

  • Schatzki ring: most common cause of intermittent dysphagia with solids

    • Fibrous stricture near GE junction in 15 % of population

    • Pts frequently present with food impacted after poorly chewed meat

    • Treatment is dilatation

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Structural/Obstructive causes

  • Esophageal webs: thin structures of mucosa and submucosa

    • Often mid or proximal esophagus

    • Congenital or acquired

    • Plummer-Vinson syndrome, with iron deficiency anemia

    • Tx is dilatation

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Structural/Obstructive causes

  • Diverticula: can be found throughout esaphagus

    • Zenker; progressive outpouching of pharyngeal mucosa above UES. d/t increased pressure when swallowing.

    • Usually seen after age 50

    • Halitosis

    • Feeling of a neck mass

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Motor lesion causes

  • Neuromuscular disorders; misdirection of food bolus,

    • liquid > solids.

    • Symptoms intermittent.

    • CVA #1 cause

    • Polymyositis/Dermatomyositis #2 causes

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Motor lesion causes

  • Achalasia; dysmotility disorder,

    • unknown cause.

    • Impaired LES relaxation,

    • absence of esophageal peristalsis.

    • Patients 20-40 yo.

    • Symptoms; regurgitation, weight loss, odonophagia

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Motor lesion causes

  • Diffuse esophageal spasm;

    • dysphagia intermittent and does not progress.

    • Tx =control any reflux present

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Chest Pain of Esophageal Origin

  • Differentiating esophageal from ischemic pain very difficult. Often not done in ED.

  • Pain at night, spontaneous onset, regurgitation, odynophagia, dysphagia, meal induced= can be seen in both

  • High admission rate of chest pain found not to be cardiac is appropiate.

  • 20-60% of chest pain is esophageal and normal coronary arteries.

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  • 25% of adults

  • Weak or transient relaxing of LES is primary cause

  • Other causes= high fat diet, nicotine, ETOH, caffeine, pregnancy, meds(nitrates, Ca channel blockers, estrogen, progesterone)

  • Heartburn is classic symptom

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  • Other symptoms= odynophagia,dysphagia, acid regurgitation, hyperslivation. Asthma exac, dental erosions, frequent URI’s, vocal cord ulcers, laryngitis, hoarseness, chronic cough

  • Postural changes in pain= increasing intraabdominal pressure can increase pain

  • Relief with antacids

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  • Complications= strictures, esophageal inflammation, Barrett esophagus (columnar epith replaces strat squamous) premalignant.

  • Pain; squeezing, pressusre-like, onset with exertion, diaphoresis, pallor, nausea, vomiting, radiation to arms and neck, shoulder and back. All similar to cardiac pain

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  • TX;

    • Avoid exacerbating agents

    • Elevate head of bed 30 degrees

    • Don’t eat 3 hours before going to bed

    • H2 blockers or PPI’s

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  • Inflammatory: can progress to ulceration, scarring, stricture

    • Reflux induced- aggressive tx. with acid suppression

    • Med induced-NSAIDs, KCL, doxy, clinamycin, tetracycline

  • Infectious: immunosuppression; AIDS

    • Candida #1, HSV, CMV, aphthous ulceration

    • Fungal, vericella, EBV.

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Esophageal Motility Disorders

  • Chest pain, dull/achy, at rest, 5th decades, intermittent dysphagia

  • Esophageal dysmotility: excessive, uncoordinated contraction

  • Achalasia & diffuse es. spasm as above

  • Ineffective esophageal motility

  • Hypertensive LES

  • Nutcracker esophagus; high amplitude, long duration contractions LES, >180 mmHg

  • Tx with NTG, Ca channel blockers

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Esophageal Perforation

  • Iatrogenic 75%

    • endoscopy #1 cause

  • Boerhaave syndrome 10-15%

    • ETOH

    • emesis

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Esophageal Perforation

  • Trauma 10%

    • Blunt rare

    • Penetrating wounds more common, often masked by more critical wounds in the area

  • FB ingestion; perforation usually at anatomic narrowings. d/t pressure necrosis(coin), penetrating from sharp object(pin), chemical irritant(battery)

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Esophageal Perforation

  • Esophageal contents to ;

  • Mediastinum-fulminant necrotizing mediastinitis and polymicrobial infection to shock

  • Pleural/peritoneal space- rapidly progressive infection/shock

  • Most spontaneous perfs through left post-lat wall in distal esophagus. Proximal perfs with instrumentation

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Esophageal Perforation

  • Pain- acute, severe, unrelenting, diffuse, chest neck and abdomen.

  • May radiate to back and shoulders

  • Exacerbated by swallowing

  • Dysphagia, dyspnea, hematemesis, cyanosis may all be present

  • Confused w/(MI, PE, ulcer, aortic catastrophe, acute abd.)= delays in dx.

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Esophageal Perforation

  • Physical; abd rigidity, hypotension, fever, tachycardia, tachypnea all common.

  • Cervical sub-q emphysema if cervical perf

  • Mediastinal emphysema takes longer

  • “Hammon crunch” air in mediastinum being moved by beating heart

  • Pleural effusion in 50% w/ intrathoracic perfs.

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Esophageal Perforation

  • CXR=suggestive

  • CT=confirms

  • Endoscopy= confirms

  • Pleural fluid aspirate= high amylase

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Esophageal Perforation

  • High mortality rate regardless of cause

    • Location, etiology, time until dx all affect outcome

  • Rapid aggressive mgt is key

    • Tx shock

    • Surgical consult

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Esophageal Bleeding

  • General approach:

  • UGIB= airway mgt., NG tube, gastric lavage, blood if needed, GI consult

  • 60% vericeal bleeds resolve w/ supportive care. 80% if bleed is not vericeal.

  • If continue to bleed= early endoscopy

  • Pharmacologic= somatostatin analogs

  • Balloon tamponade= last resort

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Esophageal Bleeding

  • Varices:

  • Seen in chronic liver ds & portal HTN

  • 60% of pts with chronic liver ds.

    • 25-30% experience hemorrhage

  • Varices from ETOH abuse have higher risk of bleeding

    • 2/3 that bleed have recurrent hemorrhage

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Esophageal Bleeding

  • Varices:

  • Endoscopy first line to control bleeding

  • Sclerotherapy and ligation are alternatives

  • Despite tx, mortality remains high

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Esophageal Bleeding

  • Mallory-Weiss syndrome:

  • Arterial bleeding from longitudinal mucosal lacs. of distal esoph/prox stomach

  • 5-15% of UGIB

  • 4th – 6th decades

  • Acute onset of UGIB

  • Overall low relative incidence of surgical intervention or adverse outcomes is seen

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Esophageal Bleeding

  • Mallory-Weiss syndrome:

  • Initial tx = supportive, most stop spontaneously

  • Ongoing bleeding= electrocoagulation, sclerotherapy, laser photocoagulation, angiographic embolization, surgery.

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Esophageal Bleeding

  • Esophageal Cancer:

  • Heme-positive stools

  • Uncommon cause of significant UGIB or LGIB

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Swallowed Foreign Bodies


Chapter 76

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Swallowed FB

  • Peds 80% of all cases

  • Prisoners, psych, edentulous adults

  • Adults=meat and bones

  • Peds = coins, toys, crayons, pen caps

  • Psych and prisoners = unlikely objects, spoons, razors

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  • Most pass spontaneously

  • 10-20% require some intervention

  • 1% surgical

  • Most are at “anatomic narrowings”

    • Peds: cricopharyngeal(C6) most common, thoracic inlet(T1), aortic arch(T4), tracheal bifurcation(T6), hiatal narrowing(T10-11)

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  • Once object passes pylorus, usually passes out with stool.

  • Irregular or sharp edges may lodge anywhere though.

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Clinical Presentation

  • Objects in esophagus:

  • Anxiety, discomfort, retrosternal pain, retching, vomiting, dysphagia, choking, coughing.

  • In peds= refusal to eat, vomiting, gagging, choking, stridor, neck or throat pain, increased salivation, inability to swallow.

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Clinical Presentation

  • Physical exam:

  • Nasopharynx, oropharynx, sub-q tissue for air.

  • Laryngoscopy (direct or indirect)

  • Objects warrenting endoscopy consult:

    • Sharp/elongated, multiple FB, button batteries, evidence of perf, child w/ coin at cricopharyngeous, airway compromise, FB for >24 hours

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ED Management

  • General Care:

  • Expectant once FB past pylorus

  • If FB obstructs esoph, insert tube above FB to remove unswallowed material

  • Locate FB:

    • Standard x-ray

    • Endoscopy= locates and removes FB, procedure of choice

    • Esophagogram- consult endoscopist prior to contrast

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ED Management

  • Type of contrast:

  • Perf expected= water soluble contrast, Gastrografin

  • Aspiration is possible use Barium, Gastrografin is pulmonary irritant

  • Perf and aspiration possible: use nonionic contrast

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ED Management

  • Monitor FB progress w/ x-rays 2-4 hrs apart

  • Frequent abd exams for peritonitis should perf occcur

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ED Management

  • Food impaction:

  • Meat= time and sedation allow meat to pass. Do not allow in esoph >12 hrs

  • Endoscopy #1

  • Glucagon 1 mg IV, repeat 2 mg IV in 20 min, relaxes esoph smooth muscle

  • Nifedipine 10 mg sub lingual, reduces LES pressure

  • DO NOT use meat tenderizer d/t complications including perforation

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ED Management

  • Coin injestion: (usually children)

  • 35% are asymptomatic

  • Coins lie in frontal plane in esoph, = flat side visible on AP films

  • Coins in trachea in sagittal plane

  • Foley catheter removal if <24 hrs

    • Secondary to endoscopy

    • Protect airway first = ET tube

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ED Management

  • Button Battery:

  • True emergency, rapid action of alkaline on mucusa, burns in 4 hrs, perfs in 6hrs.

  • Lithium cells= bad outcomes

  • Mercury containing= get blood and urine mercury levels

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ED Management

  • Locate battery on x-ray

  • In esophagus get endoscopy

  • Past esophagus: asymptomatic don’t remove. Remove if not past pylorus > 48hrs

  • Most pass through body in 48-72 hrs

  • Pts with s/s of GI tract injury need surgical consult

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ED Management

  • Sharp Objects:

  • Longer than 5cm, wider than 2 cm rarely able to pass stomach.

  • Large objects(above) and extremely pointed (safety pins) must be removed prior to passing stomach. 15-35% will perf intestines.

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ED Management

  • Initial radiograph on all.

  • Symptomatic or sewing needle FB= surgical consult

  • Sharp object and asymptomatic= expectant w/ serial radiographs

    • Not passing stomach=water soluble contrast

    • First sign of perf or object not passing= surgical consult

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ED Management

  • Cocaine Ingestion:

  • Packet = condom, holds 5 grams

  • Rupture of one packet can be fatal

  • Surgery not endoscopy recommended.

  • If packet passing intact through intestinal system, may be able to wait and watch.

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  • 1. GERD symptoms include:

    • A)pressure pain

    • B)diaphoresis

    • C)nausea

    • D)pain radiation to arm/neck

    • E)all of the above

  • 2. common causes of Trasport dysphagia include all of the following except:

    • A)carcinoma

    • B)thyromegally

    • C)CVA

    • D)strictures

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  • 3. Esophageal perforation is most commonly due to:

    • A)Iatrogenic

    • B)ETOH use

    • C)Boerhaave syndrome

    • D)blunt trauma

  • 4. Of the anatomic narrowings in children the most common spot for FB’s to lodge is:

    • A)cricopharyngus

    • B)aortic arch

    • C)tracheal bifurcation

    • D)hiatal narrowing

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  • 5. Treatment for meat impaction includes all of the following except:

    • A) endoscopy

    • B)glucagon

    • C)Nifedipine

    • D)meat tenderizer

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  • 1. E

  • 2. C (CVA is a cause of transfer dysphagia)

  • 3. A

  • 4. A

  • 5. D